14
2010-01-19 JCM
Serial #:
~pplication 0 $100.00 ~9_ ~cr..:.. ofL!
o Notified Recreation (date:~
Chris Masterson 0
Christine Fulton ')1
Sue Rose 0
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Town of Wappinger
Agreement for the Use of the Town
Hall Facilities for Meetings
FOR INTERNAL USE ONLY
Received by:
Date Received:
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Agreement for the Use of the Town Han Facilities for Meetings
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Name of
1<-<1, 0 I g--'f ~ - 3%C/-07.2!
Phone No.
This will confirm the arrangements being requested for your groups' use of the Wappinger Town Hall Facilities, as
noted below:
( ) Senior Citizens Room
~ Large Meeting Room
( ) Other: Specify:
The group is n<:! ex~ed to exceed ~ons
Date(s):~0.z~ilOjO 'i71tu~ ,;o/zll/tJTime: /:2!~(Jf/?') - 5"!c')()~/?J
It should be understood that groups using the Buildings' Facilities for evening meetings must select dates when
Town Meetings are normally scheduled (i.e., Justice Court, Planning Board, etc.) Special requests will be
considered upon their own merit, and arrangements can be made for access to, and closing, the building at the close
of your meeting.
You and your Organization hereby agree to adhere to the rules set forth on the attached page by signature of an
authorized member of your Organization or group.
The Town of Wappinger reserves the right to suspend temporarily this agreement should the Town have need of the
facility for its own purposes. Advance notice will be given as soon as possible on such occasions.
The Town Clerk should be informed promptly of any schedule change or cancellation of your group activities.
Arrangements for access to specific area to be used should be made with the Town Clerk at the time this form is
submitted.
No application shall be considered approved until it has been submitted to the Town Clerk for review and
Clearance.
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201O~01-19 JCM
Terms of the agreement must be strictly adhered to by the contm:ting group as any disregard or abuse of the rules
for use of the facilities will result in termination of use by the offending group, and they will not be granted
reinstatement.
I have read and understand the rules and regulations for the use of the Facilities in the Town of Wappinger Town
Hall, and will comply with these requirements.
Signed:
For:
(Name of Group or Organization)
Date:
Approved:
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Town Clerk
Date:
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American
Red Cross
New York-Penn
Blood Services Region
378 Violet Avenue
Poughkeepsie, N.Y. 12601
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ACORiJ CERTIFICATE OF LIABILITY INSURANCE
'-' , ~ 07/2612010
I PROfltJCsl\ nilS CJ:lRTIFICAlION IS ISSUED AS A MA.nEft OF INFORMATION
I Marsh USA Inc. (Philadelphia) ONLY AND CONFERS tII0 ~GHlS UPON THE CERTIFICATJ:l
Two Logan Square HOLDE ft. THIS CERTIFICATE DOES NOT AMEND, EXl'END OR
I Philadelphia, PA 1Q103 AL TEFt TI:II; CO'l.1ORAGE AFFOReEO BY THE POLICIES BI;LOW.
215.246.1000 fax215.246.1399 ...
Ann: Redc:ross.O!lrtreqtlest@mllnlh.com ~
84942a-SrR..cAS-1o-11 NY NY CLI! MOr MAIL INSURERS AFFORDING CO~~GE NAlCfI.
INSURm INSURER A: Old Republic In.suranCB Co 24147
NY PENN REGION .
AM!RrcAN NATIONAL REO CROSS INSURER B: ~
825 JOHN ST~ET Jr'iSURER C:
WEST HENRIETTA, NY 14586 ~
INSUR!R D: ~
INSURER E: fi
CO\'ERAGES
n-tE POLfCII:S OF INSURANCE USTEO BeLOW HAVE 8EEN ISSUED TO n-tE INSUREiQ NAMED ABOvE FOR THE POLICY pl;RrOD INDICATED.
NOTWITHSTANDING ANY REQUIREMEN'/'. TERM OR CONDrTlON OF ANY CONTRACT Ol'! OTHE'R DOCUMENT WITH RESPECT TO VllHICfot THIS CERTlFICA'l'E
MAY BE ISSUED Ol'! MAY PERTAIf04. THE INSURANCE AFFORDED BY THE POLlcn.s DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMs, exCLUSIONS AND
CONDITIONS OF'sUCH POLICIES. AGGREGATE LIMITS $I-jOWN MAY HAVE B!:EN REDUCED ey PAID CLAIMS.
HIll A~~ TYPE OF INstJRANclO POUCY NU~R POUCY ~EVlTVE PQlJCYEXI'lM.'\"rc/j UMITS
Lm INS DATE (IIII/PM'Y'n') IIATE (MM/DIlIVy'(yJ
rOENERALr....SIUTY MWZZ 50583 07/0112010 07/0112011 UR~ IS- 5n~
A ~~~~=~n~\ 5.000.000
~ COMMeRCIAL GENER.o.l. LIABILITY r $
Ix 00 Cl.AJMS MADe D OCCUR !: MED EXP (Any one p8fmn) .$ 10.000
SIR $100,000 I' ~SOIIiAL & ADV NJIJ~Y $ 5,000,000
GE!NEFU,L AOOREGAl'E $ 5,000.000
GEf04ERAlA~n.U~~lr ~IEiS PE~ t PRQoUCiS - COMF>IOP AG{ $ INCLUDED
!xl POLICY JECT LOC
A Atn'OMoBH..E LIABILITY 07/01/2010 07101/2011 COMBINED SINGle liMIT $ 5,000.000
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I- ALL O'ANED AUlOS fPd~~~nw~ -, !' BOCljL Y INJURY $
'-- ~[Q) r (Per ""iwl)
- SC!fEDUlED AU106 i:
HIRED AUTOS BOoIL Y INJURY $
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NON.QV\,t.jED AUlDS " (P<lor ~dBnl)
~ Auto ~hYsical Damage. JUV 26 2010 PROPEI'!1Y DAMAGE $
V . ~ (Perocaaenf,)
GAAAOE UABIUTY laWN OF WAPpn i AUTo ONLY - EA ACCIDENT $
==1 my AUTO IGER OTHER THAN E!A ACc $
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TO\M^' r", ,.._ !' AUTO QNL Y: AGG $
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EXCE$51 UMBIW..lA UABlUTY ... 'I~ 1 " EACHOCCURRE~ $
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:::J OCCUR 0 CLAlMS MAI:ll; i': AGGRE~A'TE $
j' $
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H OEDucrIBLE! i: $
RETENTION $ ~l I..
A WORKERS COMPEtaAnOH JUlIo MWC11670800 (Inli'ured) 07/0112010 07/01/2011 ,X v.cSYATlI. JOIk'.
EMPLOYER$' L.IAIJIUTY MWFEX146 (F'L)" 07/01/2010 07/01/2011 .L. EACI-I ACCOENT ~ 1.000,000
A ANY PROPRlErORIPARlNERJEXECUThIE Y / N MWXS908 (AL,CA,GA,MA.Mr, 07/0112010 07/01/2011
OPFICERIMBlBER EXCLUDE01 W .L. DISeAsE - EA EMPLO'VEf $ 1.000.000
A MO,OH.F'A,TN.VA)".
I b~lI1dato?:~t~r' desotibB ~nd... i;: .L DISEASE . POLICY LIMIT $ 1,000.000
l"eC1AL 10 S DelOW
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OESCRIP110N OF OPERATION$Il.OOAnoNSNE!lfICLESlEXCW$I(INS ADDED BY EfGORSI!MENrISPECIAl PROVISIONS
: RE: SLOOD DRIVES TO BE HELD THROUGHOUT THE POLICY PERrOD. 07/01110 TO 07/01/11.
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CERTIFICATE HOLDER
CLE-002473627 -03
CANCELLATION
SIlOULD ANY OF n;tE ABOVE DeSCRlB~D POUCIES HI! CANCELl.ED BEFORE THE 1
EXPIRAlION PATE lHEAEOF, TIlE I$$U1NG INSVReR WILL ENDeAVOR TO MAIL.
~ gAYS WRI1i'J;N'NOTlCE TO THE ~ERnFlCA'rE HOLD~ NAMED 10 THe !.EFT.
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!IUT F""WRE TO DO so SHALL IMPOSE ~O OElUGAnQN OR LIA8IUTY OF ANY KIND
UPClI\i nlE INStIllER. ITS "AGENTS Oil ~"REseNTAl1VEs.
A.wt.~~~N'1I\T1VE
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@1988.2009ACOftD CORPORATION. All Rights RHorved
The ACORD name and logo are registered lt1arks of ACORD
TOWN OF WAPPINGE~
ATTN: CHRISTINE FULTON
20 MIDOLEBUSH ROAD
WAPPINGER, NY 12590
ACORD 28 (2009101)
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IMPORT ANT
If the certificate horder is an ADDITIONAL INSURI::eD, the polio;y(h~s) must be endOrsed. A statement
on this certificate does not confer rights to the certificate holder In lieu (If such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not Conrer rights to the certificate
holder in lieu of such endorsement(s), ,
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certifrcatehillder, nor does it affirmativelY or negatively amend,
extend or alter the coverage afforded by the policies listed thereon. :,
AcOrd 25 (2009/01)
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ADDITIONAL INFORMATION CLE:-002473627-03 I IlP, TE (IIIM1DDIVV)
0- 01/2612010
I'ROIlUCER ,
Mal'$h USA Inc. (Philadelphia) "
Two L.ogan Square
Phlladlllphia, PA 19103 ,
215.246.1000 fax:2H5.248.13lXl .
Atln; R.flIdctQliIS.certrequm~marSh.com : "
84942B-SIR..cAS-10-11 N NY CUE MOl MAIL INSURERS AFFORDING COVERAGE NAle.
INSURED .
INSURER F; ~
NY PENN REGION II\I$URER G:
AMERICAN NATIONAL RED CROSS ~
825 JOHN STRE~ INSURER H: ti
WEST HENRIE'TTA, NY 14088
INSURE/l t ~
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ATTACHING TO AND FORMING PART O~ THE AMERICAN NATIONAl. RED CROSS CER.JIFICATE OF INSURANCE
AS RESPECTS WORKERS COMPENSATION;
This is to certify that all American NatiOl'1l1l Red Cr~ units In the following states are currenu). self Insufed thr~ugn the American National Red Cross:
Alabama, California, FIQrida. Georgia, Massachl,l~etts. Mlchigim. Missouri, Ohio. Pennsylvania, Tennessee. anCl Virginia.
Worke~ Compensation Policy tMWC 11670800: "
Policy for all other states except the mono~lililtic states of North Dakola, Puerto Riet;>, Washington, \/Ifyomlng and U.S, Virgin 1~Il!nds and !he liielf-insured
states of Alabama. California. Florida, G~ol'Qi8. Massachusetts. Mlehiaan, Missouri, 01'110. Penn,.ylvama. Tenne6See. and Virginia. InclUrlli\1ii Employers
Uability for monopolistic states of North Dakotil, Puerto RIco, Washington, Wyoming, and U.S, Virgin h.llInds. ,
.Specific Excess WorKers Compenliiati9n poncy ltMVllFEX14f:l: '.
American NaliQnal Red Craliilii ill self.lnsu/lild for Workers CQmpensation in the stala of Florida~ The excess Uallility limit Is Subject 10 lit stata approved Self-
Insurad Retention.
-Specific Excess Worka~ Compensation PQlicY. #MWXS908: "
Amerlean National Red Cross Is SQlf-in&Ured for Worksn; Compensation in the fOllOwing IlItates: Alabamll, Callfo.mia. Georgia. Ma&sachusens. Michigan,
Missouri, Ohio, P8nnsyt~nia, Tennessee and Virginia. The Excess Liability limits are liil,lbject to state epproved:.Self-lnlWred Retentlonlii.
This certificate is issued as a matler of Inforrn!ltion only and confers no rlgnts upon the ceT1ificate holder.
CeRTIFICATE HOLDEll
TOWN OF WAPPINGER
ATTN: CHRISTINE FULTON
20 MIODLEBUSH ROAD
WAPPINGER, NY 12590
AI1lIIDRlZED REPRESlalllllTlIII!
ar Manotl \I$A InQ. ,
Roger C Fell '
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.Joanne M;"eIIlUO
ClIent Flopr~ gntailva
Marsn USA Ine.
Tw::> Logan $.quars
Philadoli=Ha~PA 19103
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Joannl!l.Ml!lIliiZzo~marah.com
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To Whom It May Concern:
Re: Certificate of Insurance
The enclosed certificate is being sent to you to respond to your re~nt request
Please note that the Red Cross has an online Memorandum of Insurance (MOl). The
Memorandum of Insurance will provide you with a more efficient way of obtaining
information about Red Cross insurance coverage and can be accessed from the
following websites:
WNW. marsh.com/l11oi?cl ient=2077
www.redcross.org (the Red Cross public website). Len click on th~ heading "Working
with the Red Gross" and find the MOl link at the bottom of the pag~ at "Related Links."
Should you have any questionsl the contact person listed on the Memor~dum website
is available to assist you or you may contact a Risk Mar:tagement representative from
American Red Cross national headquarters at (202) 303-7290.
~ "".1Sh ~ _~ Compllllll!5
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American
Red Cross
Blood Services
New York-Penn Region
825 John Street
West Henrietta, NY 14586.9780
(585) 7~O-5555
FAX COVER
DATE: 07-.J....(; ~/o
TO:C~-" ~
Pages sent, incIu~g t4is CO'Vel": ~
FROM:: BONNIE :M:OSAKOWSKI
PHONE:
FAX: gl.f~ .~ 9 7- Tf~r g
PHONE: 585-760,-5798
FAX: :585-760-5767
SUBJECT:
CERTIFICATE OF INSURANCE
OURGENT
'jn'OR REVIEW
o PLEAS); REPLY
MESSAGE:
Here is a copy of the Certificate ofInsurance/ agreement that "Yas requested for your upcomin.g blood
drive. If any changes are necessaIV. 'Please feel free to contact me at 585-760-5798 Or
mosakowskib@usa..redcross.org. Thank you. ' ·
This message is intended only for the llile of the individual to whom or entity to which, it is addressed and ma.y contai
information that is privileged, confidential and exempt from discbsure under applicable la~. If the reader of this
message is not the intended recipient or the employee or agent responsible for delivering tJ,le message to the intended
recipient, you are hereby notified that dissemination, distribution, or copying ofthisCQmmilnication is prohibited. If
you have received this communication in error, please notify us immediately by telephone;, Thank you,
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